This subtle, textured and enthralling book tells the story of the men and women who created and developed psychiatry. The men were the doctors; the women, at least for the most part, were the patients. For feminists in the recent past, keen to see patriarchal conspiracy at work, the doctors have been demons. But though there are definitely some villains among the psychiatrists here (the Victorian misogynist Henry Maudsley is merely distasteful compared to the unhinged guru Gaëtan de Clérambault, who staged his own suicide in 1934 surrounded by weird wax mannequins), Lisa Appignanesi is evenhanded in her approach towards those who sought to explore the dark continent of the diseased female mind, and to draw the defining lines between the mad, the bad and the sad.
The evidence as to whether women really do suffer from mental illness more than men is unclear, though it seems that today, at least, more women than men seek help at the sad end of the spectrum. It may be that society more often defines disordered men as bad, sending them to prison rather than to hospital. In other cases, men may self-medicate with alcohol and avoid diagnosis (of the writers Scott and Zelda Fitzgerald, whose folie was clearly à deux, she became a psychiatric patient, but he died of drink at the age of 40).
Nevertheless, culture has long associated madness with women, and the connection seems to have been intensified with the birth of psychiatry as an independent discipline around 1800. In 1810, the statues on the front of the Bedlam madhouse, representing bestial men in chains, were torn down and replaced with the iconic figure of a beautiful woman, an Ophelia or a Lucia di Lammermoor. During the same period, the French pioneer Philippe Pinel was literally liberating the insane from their chains in the aftermath of the Revolution. Rather than simply restraining patients, he was one of the first to apply close observation in an attempt to understand the inner workings of their minds.
He and his staff did not always succeed in curing their charges, but they did talk to them and attempt to empathise. The most celebrated patient, Théorigne de Méricourt, the “Amazon” who had led a Jacobin women’s brigade and whose tragic degeneration reads like a metaphor for the Revolution itself, was one of their failures. Yet the vivid description of her by Pinel’s star student Jean-Etienne Esquirol (her obsessional self-dousing with cold water, her preference for drinking from the gutter, and muttering to herself about revolutionary committees) is unmissable writing. If Esquirol seems a novelist manqué, Jean-Martin Charcot, who ran the famous Salpêtrière hospital later in the century, was more like a Svengali whose patients gave public displays of their histrionic symptoms.
One of the great strengths of this book is the way in which it charts the uncanny relationship between fashions in psychiatric theory and sufferers’ symptoms. Mental illness is much less static than physical disease; it is protean in its external expression and culturally infectious, so that once a particular diagnosis catches on, whether it’s hysteria in the 19th century, or multiple-personality disorder in the late 20th, the number of sufferers balloons. Illnesses also reflect society at large: the Victorian neurasthenic unable to rise from her sofa was symbolically enacting the limited life opportunities for women. Today’s epidemic of eating disorders reflects the media’s obsession with body image, though Appignanesi also suggests, worryingly, that feminism may have made an unwitting contribution by overemphasising the female body in its attacks on the beauty industry.
The past 200 years have seen theoretical fashion swing back and forth between the poles of nature and nurture in the attempt understand the causes of mental illness. Biological explanations and drug treatments have recently been in the ascendant, but Appignanesi sees signs that this is on the wane. She also suggests that the connection between brain chemistry and mood may prove to be a relatively empty discovery, no more meaningful, say, than the connection between emotion and facial expression. We laugh at Charcot for photographing patients’ physiognomies, but are today’s scientists any different as they peer at brain scans in the hope of locating the seat of madness?
Mental illness remains mysterious probably because it is so multicausal, with biology, culture and family dynamics all playing a role. In any case, illuminating the causes does not necessarily lead to eliminating them. The most striking conclusion Appignanesi comes to is that the percentage of cures through care has not changed since the early 1800s. With the psychiatric profession’s current manual of mental disorders running to 900 pages, she wonders whether we are guilty of overdiagnosing, pathologising inescapable aspects of the human condition. She shares Freud’s pessimism: civilisation indeed brings with it discontents, and containment rather than cure is the best we can hope for.